California Pediatric Intubation

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DesertMedic66

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The state just announced that pediatric intubation will be removed from the paramedic's scope no later than July 1st, 2018. Direct visualization will still be authorized for FBAO but no tubes on any patient that fits on the Broslow tape (under 40kg).

They may still allow flight medics and CCPs to have it in their scope but that is undecided currently.

Link: http://remsa.us/documents/memos/20171012SystemAdvisoryPedsIntubationPhaseOut.pdf
 
This is a long time coming, TBCH. It’s also something I don’t think should be restricted to just “California paramedics”, but most paramedics in general.

If I’m not mistaken, Wilco EMS’ medical director, Dr. Jarvis doesn’t allow his paramedics to intubate pediatrics as well.

Our medical director was telling me about this about a month, or two ago. We’ll see which side of the spectrum HEMS paramedics wind up on, but either way it’s not a huge deal to me.
 
VentMonkey said:
This is a long time coming, TBCH. It’s also something I don’t think should be restricted to just “California paramedics”, but most paramedics in general.

If I’m not mistaken, Wilco EMS’ medical director, Dr. Jarvis doesn’t allow his paramedics to intubate pediatrics as well.
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I have the same view. In my county we haven’t been able to intubate pediatrics (anyone under 8 years) for 5+ years.

I honestly won’t be surprised if adult intubation goes away daily soon either.
 
VentMonkey said:
:confused:Heh? Not quite sure that I follow. Why would you have to use this device more?

You do realize that there are differences in the anatomical structures of even subset age groups of the pediatric population, yeah?
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Because if I'm intubating a ped, it had better be a crash airway situation where an opa isn't doing the trick.

My point was kind of double edged. 1 being it's a truly emergent procedure, and 2, I'm doing it because nothing else is working.
 
NPO said:
Because if I'm intubating a ped, it had better be a crash airway situation where an opa isn't doing the trick.

My point was kind of double edged. 1 being it's a truly emergent procedure, and 2, I'm doing it because nothing else is working.
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That’s a 1:1,000,000 pt with completely swollen shut or destroyed airway and, quite frankly, i fail to see how tubing them would make any difference. Especially given the anatomical peculiarities of peds.
 
Qulevrius said:
That’s a 1:1,000,000 pt with completely swollen shut or destroyed airway and, quite frankly, i fail to see how tubing them would make any difference. Especially given the anatomical peculiarities of peds.
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I agree. It's going to be exceedingly rare. But I'd hate to take a ped with airway burns and a closing airway to my nearest burn hospital an hour and a half away with no airway option.

Again, I know it's very uncommon, but then again, so are a lot of things we do.
 
NPO said:
I agree. It's going to be exceedingly rare. But I'd hate to take a ped with airway burns and a closing airway to my nearest burn hospital an hour and a half away with no airway option.

Again, I know it's very uncommon, but then again, so are a lot of things we do.
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That would be the only time it is absolutely necessary. Unless there’s a facial trauma, or the medic in question is a whiz who can drop a tube through a nare.
 
Qulevrius said:
That would be the only time it is absolutely necessary. Unless there’s a facial trauma, or the medic in question is a whiz who can drop a tube through a nare.
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In school we all did clinical rotations to teach us how to do our skills.

Why does that stop when we graduate? Are we intubating weekly? Surely not.

Before we go removing things because we aren't good at them (because we don't practice them), I say we mandate annual or bi-annual clinicals for low-frequency high-risk interventions, including adult intubations.

I know nobody wants to do more CEs, but if we ever want to be considered professionals, we need to be good at what we do.
 
Qulevrius said:
or the medic in question is a whiz who can drop a tube through a nare.
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Again, a review the subsets of age groups and their airway differences would be in order. Yet another reason why the average provider has no business fiddling around down there.

We truly, and simply lack the educational know how.
 
VentMonkey said:
Again, a review the subsets of age groups and their airway differences would be in order. Yet another reason why the average provider has no business fiddling around down there.

We truly, and simply lack the educational know how.
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My point exactly. Even if a medic in question is a virtuoso and a medical prodigy, that’s exceptional. But in reality, 99% of the medics will butcher a ped’s airway trying to slip in a tube.
 
NPO said:
Before we go removing things because we aren't good at them (because we don't practice them), I say we mandate annual or bi-annual clinicals for low-frequency high-risk interventions, including adult intubations.
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Why? We’ve had plenty of time, years in fact, to remediate with no improvements. How much more time do you need?

Do you honestly feel bi-annual skills is sufficient enough to retain competency? I guarantee you it is not. I wouldn’t want a bi-annual medic anywhere near my own child’s airway, I would want an expert. I choose not to live 300 miles away from civilization for such reasons.

Maybe emphasize re-educating the basics to a tee before providing any reason why we should continue to keep a skill we continuously show now consistently positive outcomes with.

If higher level providers are allowed to keep such a skillset then you bet your arse they better be well educated in the ins and outs of airway management. Not intubations—a skill—airway management.
 
NPO said:
Before we go removing things because we aren't good at them (because we don't practice them), I say we mandate annual or bi-annual clinicals for low-frequency high-risk interventions, including adult intubations.
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I do not have the numbers off hand but even specialty pediatric teams do not have fantastic prehospital intubation statistics. I do not think there bi-annual clinicals in the solution. Most flight programs are good, but not great at it.
 
What is the proposed solution then? Someone somewhere will have a pediatric that needs an emergent airway? Are we agreeing that it's better to let the child die than attempt (and potentially fail) to manage the airway with ETI?

I suppose most all places allow needle cric, if not surgical cric, but how much safer is that? I've never been forced into that position, but my understanding is that a 10g doesn't ventilate very well.
 
NPO said:
What is the proposed solution then? Someone somewhere will have a pediatric that needs an emergent airway? Are we agreeing that it's better to let the child die than attempt (and potentially fail) to manage the airway with ETI?

I suppose most all places allow needle cric, if not surgical cric, but how much safer is that? I've never been forced into that position, but my understanding is that a 10g doesn't ventilate very well.
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Yeah, we don’t allow needle or surgical for medics in my county..

Is saving one pediatric worth killing 10 pediatric because we screwed up on the tube?
 
NPO said:
What is the proposed solution then? Someone somewhere will have a pediatric that needs an emergent airway? Are we agreeing that it's better to let the child die than attempt (and potentially fail) to manage the airway with ETI?

I suppose most all places allow needle cric, if not surgical cric, but how much safer is that? I've never been forced into that position, but my understanding is that a 10g doesn't ventilate very well.
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I do not agree with that rationale on it's premise. There are a lot of potentially life saving interventions that should not be done in the field regardless if the person would die otherwise. Yes there will be pediatrics that need emergent airway management but does that mean that every paramedic should be allowed to do it? BLS management until advanced provider is available (Closest facility, CCP in fly car, HEMS) or needle cric in peri-arrest.
 
DesertMedic66 said:
Is saving one pediatric worth killing 10 pediatric because we screwed up on the tube?
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You bring up a good point. So what are paramedics doing that is causing the harm?

Is it intubating too agressivly on patients who could have had their airway better managed with other techniques? Probably.

Is it intubating and delaying other more critical procedures trying to secure an unnecessary airway? Likely.

Is it unrecognized esophageal intubation? In some cases, absolutely.

I'd be curious to see the numbers, but if I had to take a guess, I'd guess it was a combination of agressivly intubating patients who didn't need it and delaying definitive care.
 
I don't disagree. I just think we need a fail safe. Perhaps they fail safe is HEMS with higher trained and licensed practitioners than your average street medic, or, if in proximity to a hospital, a physician.
 
NPO said:
I don't disagree. I just think we need a fail safe. Perhaps they fail safe is HEMS with higher trained and licensed practitioners than your average street medic, or, if in proximity to a hospital, a physician.
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Or instead, the medics could be rotated with anesthesiologists the same way RTs are.
 
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